Management of Patients with Node-positive Prostate Cancer at Radical Prostatectomy and Pelvic Lymph Node Dissection: A Systematic Review

Abstract

Introduction:The optimal management of prostate cancer (PCa) patients with lymph node invasion (LNI) at radical prostatectomy (RP) and pelvic lymph node dissection (PLND) still remains unclear.Objective: To assess the effectiveness of postoperative treatment strategies for pathologically node-positive PCa patients. The secondary aim was to identify the most relevant prognostic factors to guide the management of pN1 patients. Evidence Acquisition: A systematic review was performed in January 2020 using Medline, Embase and other databases. A total of 5,063 articles were screened and 26 studies including 12,537 men were selected for data synthesis and included in the current review according to the PRISMA recommendations.Evidence Synthesis: Ten-year biochemical recurrence (BCR)-, clinical recurrence (CR)-, cancer-specific (CSS)-and overall (OS)-survival rates ranged from 28% to 56%, 70% to 92%, 72% to 98% and 60% to 87.6%, respectively. A total of 7, 5, and 6 studies assessed the oncologic outcomes of observation, adjuvant radiotherapy (aRT) or adjuvant androgen-deprivation (ADT), respectively. Initial observation followed by salvage therapies at the time of recurrence represents a safe option in selected patients with low disease burden. The use of aRT with or without ADT might improve survival in men with locally advanced disease and a higher number of positive nodes.Risk stratification according to pathological Gleason score, the number of positive nodes, pathological stage and surgical margins status is key for risk stratification and selection of the optimal postoperative therapy. Limitations of this systematic review are the retrospective design of the studies included and the lack of data on adverse events. Conclusions:While the majority of men with pN1 disease would experience BCR after surgery, long-term disease-free survival has been reported in selected patients.Management options to improve oncologic outcomes include observation vs. adjuvant therapies such as aRT and/or ADT. Disease characteristics should be used to select the optimal postoperative management for pN1 PCa patients.

The role of lymph node dissection in salvage radical prostatectomy for patients with radiation recurrent prostate cancer

“… 20 , 21 , 22 However, due to the different natural history of radiation‐recurrent PCa undergoing SRP, data from primary radical prostatectomy cannot be extrapolated to radiation‐recurrent PCa patients planned for SRP. 16 , 17 , 23 In a report from the Surveillance, Epidemiology, End Results registry (SEER) evaluating 364 patients who underwent SRP between 1988 and 2010, Pokala et al 24 did not find a significant association between the number of RLNs and cancer‐specific survival (HR 0.5, 95% CI: 0.2–1.4, p = .2). 24 However, a more recent analysis of the SEER database which included patients who were treated between 2004 and 2016, Wenzel et al 25 did demonstrate a significantly lower cancer‐specific mortality with a higher number of removed nodes (HR: 0.61, CI: 0.40–0.91; p = .02).…”

Clinical outcomes of salvage treatment in lymph node-positive prostate cancer patients after radical prostatectomy

“…According to the previously published data, adverse pathological features in prostate cancer include positive resection margin, seminal vesicle invasion, and extracapsular extension [22,23]. In particular, Gleason score � 8 and a high number of positive nodes in LNP prostate cancer are also known as aggressive pathologic characteristics [5]. However, most of the pathological factors that were examined in this study were not significantly related to the outcomes of salvage treatment for LNP prostate cancer.…”

“…Of all prostate cancer patients who receive RP and pelvic lymph node dissection (PLND), 3-14% have pathological lymph node-positive (LNP) disease [1][2][3]. Several previous studies showed that LNP was associated with poor prognosis in prostate cancer patients who received RP as initial treatment [4][5][6]. Nonetheless, the optimal management of patients with LNP still remains unclear.…”

PSMA PET-CT in the Diagnosis and Staging of Prostate Cancer

“…It is not clear, however, if ePLND should still be based on a nomogram calculation of an individual’s risk of LNM or PSMA PET-CT findings alone. Traditionally, PLND is considered only valuable for prognosis as correctly identified pN1 patients typically benefit from adjuvant therapies [ 51 ]. This is supported by research that has failed to demonstrate an oncological benefit for lymphadenectomy or its extent [ 52 , 53 ].With the new lens of PSMA PET-CT, new studies have demonstrated 50% of suspected LNM lie outside the boundary of ePLND [ 54 ].…”